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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006529
Report Date: 02/07/2025
Date Signed: 02/07/2025 10:15:55 AM

Document Has Been Signed on 02/07/2025 10:15 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GOLDEN HEARTS ELDERLY CARE 2FACILITY NUMBER:
306006529
ADMINISTRATOR/
DIRECTOR:		ELAHI, NARGISFACILITY TYPE:
740
ADDRESS:25231 ROMERA PLACETELEPHONE:
(949) 716-0016
CITY:LAKE FORESTSTATE: CAZIP CODE:
92630
CAPACITY: 6CENSUS: 3DATE:
02/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:04 AM
MET WITH:Nargis Elahi - Administrator/Licensee TIME VISIT/
INSPECTION COMPLETED:
10:30 AM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Andrea Mendivil made an unannounced case management visit in conjuction with ongoing complaint investigation for complaint control # 22-AS-20250110122555 . LPA was greeted and granted entry into the facility by Noor Elahi, Caregiver and explained the reason for the visit. Administrator/Licensee Nargis Elahi arrived shortly after.

Per review of LIC 500 Personnel Report received on 02/03/2025 the facility personnel record indicated that that Staff 1 started working at the facility on 10/2/2024. Per review of both Guardian and internal system for CCLD indicate S1 is not associated with Golden Hearts Elderly Care 2.
S1 was advised to leave the facility and Staff 3 (S3) and Administrator took over care of the residents.

Per review Staff 2 (S2) on LIC 500 started on 01/23/2025 and based on Administrator S2 worked a minimum of 5 days in January 2025. S2 was not associated to Golden Hearts Elderly Care 2.

Based on observations made during today's visit deficiencies are being cited. An immediate civil penalty is assessed. An exit interview was conducted and a copy of this report was provided along with appeal rights.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Andrea Mendivil
LICENSING EVALUATOR SIGNATURE: DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/07/2025 10:15 AM - It Cannot Be Edited


Created By: Andrea Mendivil On 02/07/2025 at 08:24 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GOLDEN HEARTS ELDERLY CARE 2
FACILITY NUMBER: 306006529

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/08/2025
Section Cited
CCR
87355(e)(2)

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(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Licensee/Administrator agreed to associate both S1 and S2 to the correct facility and provide proof to LPA by POC due date.
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This requirement was not met evidence by S1 and S2 were not associated to the facility. This poses an immediate health and safety threat to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alisa Ortiz
LICENSING EVALUATOR NAME:Andrea Mendivil
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2025


LIC809 (FAS) - (06/04)
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